The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?

Hemophilia.

Congestive heart failure.

Kawasaki disease.

Rheumatic fever.

Answer and Explanation

The Correct Answer is C

Choice A reason: Hemophilia causes bleeding issues, not a strawberry tongue, which is a mucosal symptom. Kawasaki disease’s characteristic tongue appearance matches the description, making this unrelated and incorrect compared to the specific disorder associated with the child’s reported tongue manifestation in the assessment.

Choice B reason: Congestive heart failure affects cardiac function, not oral mucosa, and doesn’t cause a strawberry tongue. Kawasaki disease is the condition linked to this symptom, making this irrelevant and incorrect for the nurse’s recognition of the child’s tongue appearance in data collection.

Choice C reason: A strawberry tongue, with a red, bumpy appearance, is a hallmark of Kawasaki disease, often seen with fever and rash. This aligns with pediatric infectious disease criteria, making it the correct disorder the nurse recognizes based on the caregiver’s description of the child’s tongue.

Choice D reason: Rheumatic fever may cause oral symptoms but not a classic strawberry tongue, which is specific to Kawasaki disease. The latter’s mucosal findings are distinctive, making this less accurate and incorrect compared to identifying Kawasaki disease as the cause of the tongue manifestation.

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Correct Answer is C

Explanation

Choice A reason: Gown, handwashing, and gloves are used for contact precautions, not droplet precautions, which require a mask to prevent respiratory droplet transmission. Pneumonia spreads via droplets, making gowns and gloves excessive, and this combination incorrect for the specific infection control needed in this scenario.

Choice B reason: Handwashing and gloves protect against contact transmission but do not address respiratory droplets in pneumonia, which requires a mask. Droplet precautions prioritize airway protection, making this incomplete and incorrect for the nurse’s protective measures in caring for a child with pneumonia.

Choice C reason: Droplet precautions for pneumonia require a mask to block respiratory droplets and handwashing to prevent fomite transmission. This combination aligns with infection control guidelines for droplet-borne infections, making it the correct choice for the nurse’s protective measures in this clinical scenario.

Choice D reason: Gown, gloves, and mask are used for airborne or contact precautions, not droplet precautions. Pneumonia requires only a mask and handwashing, as droplets are the primary transmission mode, making this excessive and incorrect for the specific precautions needed for this child’s care.

A. “We hold a family meeting to explain to our other children that she gets away with things they will not get away with because of her impairment.” B. “We always take away a privilege our child has been looking forward to, such as going to a movie next weekend.” C. “My wife and I just ignore the behavior and if there is a mess, clean up the mess. He doesn’t understand that he has an impairment.” D. “We wait until a behavior happens a second time and immediately put our child in time-out.”

Correct Answer is D

Explanation

Choice A reason: Explaining differential treatment to siblings fosters resentment and doesn’t teach the impaired child. Time-out after repetition reinforces boundaries, making this unhelpful and incorrect compared to a direct discipline strategy addressing the cognitively impaired preschooler’s continued behavior effectively.

Choice B reason: Taking away privileges like movies is too abstract for a cognitively impaired preschooler to connect to behavior. Immediate time-out is clearer, making this ineffective and incorrect compared to a concrete, immediate consequence tailored to the child’s cognitive limitations in discipline.

Choice C reason: Ignoring behavior and cleaning up avoids teaching consequences, reinforcing unwanted actions in a cognitively impaired child. Time-out provides structure, making this counterproductive and incorrect compared to a strategy that directly addresses and corrects the preschooler’s behavior with appropriate discipline.

Choice D reason: Waiting for a second occurrence and using immediate time-out provides clear, consistent consequences, suitable for a cognitively impaired preschooler’s understanding. This aligns with pediatric behavioral strategies, making it the correct statement reflecting effective discipline for the child’s continued behavior issues.

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The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a client’s chart and notes that the child is in droplet precautions for pneumonia. What protection would she need to take in caring for the child?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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